Archive for March 26, 2011

Nou vin pou chache lavi – We’ve come looking for life

 

I

As a young American, I think I’ve been raised to believe in the power of my own capabilities, in making decisions about my life and having some sort of personal control over the events that transpire, or might transpire in it. I’d say that we’re a very anthropocentric culture, meaning that we regard the world as existing for us as individuals, and that the only valid reality is that which springs through our own perspective as human beings. It is a worldview that bestows a lot of power on the individual, in which we’re left to our own devices to shape our world. Indeed, it means that the world can be and is shaped by us. It gives us the power of possibility.

The other alternative is the inverse of this:  that in fact, it is us who are shaped by elements beyond our own power. One aspect that I’m interested in learning about here in talking with migrant Haitians is this concept of having some sort of power in life, of feeling capable to do certain things in life and have hope for something that can be attained later. Life in rural Haiti exposed me to a worldview that was less human-centered and more cosmo-centered, one in which an individual is a member of a much larger, interconnected community of not only family members and neighbors, but of spirits and other-worldly forces. This worldview emphasizes the relationship of an individual to others and an individual’s relationship to the more spiritual – a God, the spirits of the dead, and spirits both benevolent and evil. Furthermore, an individual is more than body and mind; I heard explanations that each of us has a “little good angel” inside us, as well as a “big good angel” – “when you dream, and you see yourself somewhere else, that is your big good angel that has left.” And these different components to the self can be influenced and possibly harmed by outside forces. Illnesses may be “natural,” “sent,” or “moral,” and can each affect different components of the self.

In rural Haiti, where people are very poor, it might seem only natural that an individual bands together with family and neighbors to survive. Traditionally, families organize themselves in lakou-s, in which members of an extended family build their houses around a central courtyard and share resources and responsibilities. There are fascinating examples of solidarity with wonderful names – tet ansanm, or “heads together,” in which men may organize themselves to farm someone’s field by hand – as nothing is mechanized in rural Haiti. Tet ansanm is referred to as a thing in itself, as in, Nou fe yon tet ansanm, or “we make a heads together.”

Life in rural Haiti is built on an individual’s relationship to others, in the life that we experience and determine, and the relationships with whatever may lie beyond it, outside it, within it, and which in turn shapes and determines us. The distinction between the two – us as actors in our own play, and the spirits or forces who may be directing the play, or changing the script – isn’t so distinct either, or impenetrable. Life is explained by something more fluid, something that allows a more distributed ebb-and-flow between us and the more powerful. People qualify their hopes, not matter how small in passing conversation, with the saying, si dye vle – “if God wills it,” as in, “We’ll see each other later, God willing,” and when asked how they are, people may say, “I’m no worse, grasadye” –  thanks to God. So by understanding how an individual in another culture may feel some sense of self-determination, we learn about the importance of these relationships between the individual and other members of the community, and between the individual and the more spiritual.

II

As we go about it, we realize that even our concept of time reflects our own belief in the power of ourselves as individuals. For example, suppose you were asked the question, “In the future, where do you imagine yourself?” I wouldn’t be going out on a limb by saying that most of us are pretty motivated individuals, who feel very capable of making decisions and determining “the future.” By “imagining myself,” I see a self that will, hopefully, result from actions I take, actions that I’m capable of taking. I’m even optimistic about it.

Interestingly, there are two ways of saying “the future” in Haitian Kreyol: laveni, which is close to its French root, l’avenir; and demen, also rooted in French, but with a subtle but very important difference:  demen literally means “tomorrow.”  When a typical Haitian migrant, one who, for lack of economic means may have received only a little primary education in Haiti before leaving, is asked to reflect about “hope for the future,” we’ve found that demen seems better understood than its more abstract, rather elite counterpart, laveni. We could say that for them, “the future” might even be conceptualized differently – it may be, quite literally, “tomorrow.” In a world where your existence is a near-daily struggle to find work, in order to obtain money, in order to buy food, there seems to exist a different time scale altogether.

So taking all of this together – that some of the migrant Haitians here may have come from a life in which their individual story was played out on a backdrop of others they knew intimately, where their very survival, despite the solidarity and resourcefulness they may have had in Haiti, was so threatened that they felt compelled to come here – what happens to their concept of human potential, of agency, of power in shaping their own lives when they find themselves in another country, and where they may have come without knowing anyone at all? How has their experience of migration influenced their perceptions of themselves and their relationships with others?

Obviously, they must have felt some power to improve themselves, as they made the decision to come here. “Ti malere nou ye, nou vin pou chache lavi,” said a rice farmhand I met here – “Us little miserable ones, we came looking for life.” Even referring to yourself as a ti malere – a little miserable person – speaks volumes…and what is the life they’re looking for?

III

But before we go out to the migrant communities, let me paint a picture for you:  San Francisco is a bustling, busy, noisy, and at times smelly city. Tourists do not come here, mostly because, being landlocked, it is not near a beach. Jenny said herself that it isn’t exactly the scenery that keeps bringing her back. Walk down the little residential street where Rosa lives, past the old woman who sells clothes and sandals outside her garage; past the guys who are always standing around on the corner talking; past a man pushing a wooden cart selling coconuts and pineapples; past a beat-up pick-up truck with enormous speakers blasting an advertisement for the bottled water loaded in the back; past little chihuahuas that bark their heads off at you; past kids in blue uniforms going to school; and then you get to the Avenida Libertad.

This street, or rather avenue, can feel like a death trap for a pedestrian – but that’s probably only me, as the locals never seem fazed by any of it. There are two strips of pavement divided by a median with some grass. Note that I said “strips of pavement;” there are no marked lanes. There really isn’t even a respected right-of-way. Most Dominicans don’t own cars. Instead, they use mopeds and scooters and little 150cc motorcycles, and they drive them in any direction that’s feasible for them to get to where they need to go. This means that as you cross the street, someone who would have otherwise remained on the side of the road in which you’d expect him to stay, may decide to pass the car in front of him altogether by going against traffic in the oncoming direction and cut straight across the path you’re walking down. That happens all the time. And “the sidewalk” is also known to accommodate two-wheeled vehicles from time-to-time.

The sidewalk is, in itself, an adventure. There are mechanists’ shops on nearly every corner, where men sit around working on their scooters or motorcycles, the grease and oil all over the sidewalk in front of you. The gutters would make for tank traps. They can be huge – a massive drop-off from the sidewalk to the street, and full of all kinds of debris and fetid liquid. I remember walking with Sylvie  to her little shop in the market and seeing a hole with rebar protruding from it directly in the middle of the sidewalk. We take for granted our public infrastructure….

The market is an affair to behold. To really get a full-on, all-senses experience of the community you are living in, I recommend spending time in its market. These are situations in which you are observing everything and always moving. There are fruit vendors; people slaughtering chickens and selling them directly to women to take home that day; there are kids who will laugh and play with you; there are men who will stare at you wondering why any of this is deserving enough for someone to stop and take a picture; there are young Haitians walking about selling CDs; there are Dominicans sitting in doorways; there are stalls of cooked rice and chicken; a man cutting open coconuts to sell; a throng of people in all directions; and always music. Music is everywhere all the time. It’s like a never-ending competition to play it louder than the next person who comes along. Some cars come by that are deafening and would make me, anyway, stop in conversation because I can’t hear; there are people with speakers in their windows who play their music out onto the street; there are more pick-up trucks with speakers in the back advertising something or playing more music; and always the sound of two-wheeled motorized vehicles zipping about.

Then when you come back to the residential area after dodging traffic across Avenida Libertad, you pass by a little family sitting in chairs on their front patio talking; you see motorcyclists zip by and wave or yell out to someone they know; kids with home-made kites. Everyone knows everyone in their neighborhood, claro….

IV

From here, let’s take a detour for a bit, to the Hospital San Vicente de Paul, the public hospital in San Francisco de Macoris. Earlier in the week, I met this great guy named Jhefri (pronounced “Jeffrey”) who is studying law at the CURNE (the local university that partners with Emory School of Nursing) and speaks really good English. I asked if he’d be interested in doing some translation work for me when I interview Dominican healthcare workers and others, and he agreed.

Jhefri is a fantastic person who’s very bright and polite to the bone. When he met up with me to go to the hospital, he was carrying his little book on Dominican Civil Code, and sat on Rosa’s front porch in a rocking chair reading it quietly while I was finishing up a phone call. “Some of the presidents think that the Constitution is a piece of paper, but I do not think this. I think the opposite in fact. The problem isn’t the Constitution, it is the person.”

Jhefri is full of wonderful facts and historical lessons. He will recall the dates of Trujillo’s reign, the American intervention beforehand, and when the Haitians invaded the island and the Dominicans fought for their own independence from Haiti in 1844 – that’s right, the Dominican Republic was once ruled by their neighbors to the West – a fact that, in no small part, contributes to the argument of a racist minority that Haitians are hell-bent on re-conquering the whole island. “We are one island, but two different countries. Lots of Haitians come here to work – in the plaintains, rice, peppers, ice cream sale, cell phone chargers, lottery tickets, a watchman, you know, the one who looks after a house? Housekeeping, but you know, many Dominicans don’t want to hire a Haitian to be a housekeeper, because they think they are thieves. This is the problem between them and us.”

Jhefri spent time in the United States in fact, last summer. He lived, among all places, in Custer, South Dakota, working on a dude ranch. “You know this dinner? Chuck-wagon dinner?” I had to laugh. “Yes man! I love this dinner!”

As we go through the gates of the hospital, we see a group of men wheeling a man on a gurney across the busy street of motorcycles and mopeds and cars and buses. The man is on his back with an IV running into his arm, and they’re on the way to the radiology center, which is across the street from the hospital.

As we wait to talk with a Dominican nurse, we meet a Haitian family standing in the hallway. We go outside together as a group to talk. Their nine year-old son was shot in the leg with a homemade gun, it seems. “How do the Dominicans treat you here in the hospital?”

“If you have money, they’ll take your case right away,” the mom says. “Otherwise, they treat you like dogs.”

Now let’s go inside, to meet a Dominican nurse with twenty-four years’ worth of experience. She’s seen all matter of things. She doesn’t want to be voice-recorded. Jhefri explains to me that she is concerned that I work for the WHO. I roll through my well rehearsed introduction, that I am a student from America, that I work with colleagues whom she most likely knows very well, that this project is to understand the problems between Haitians and Dominicans, and that all the information obtained from people here is confidential, meaning I’m not sharing anybody’s name.

“A lot of Haitians come here,” she says. “But we treat everyone here the same – igual – regardless if they’re Haitian or Dominican. You must understand that we’re a poor hospital. We get a lot of money from the government, but it isn’t enough. Our economy just isn’t developed. All institutions in the Dominican Republic need assistance. So we do what we can.

“But the Haitians don’t feel that way. Even if we give them good treatment, even if it’s the same that we’d do for a Dominican, they don’t believe us, and they think the reason why they may not get better is because of us, and not because of their illness. So they end up not listening to us, not doing what we tell them, and they get sicker. It’s a cultural problem, and a language problem. We don’t have a translator, so we talk to whoever speaks Spanish best among them.”

“What kind of problems do the Haitians have who come here?”

“Multisystem trauma…”

“From what?”….interesting that the first thing that comes to her is injury associated with accidents or violence.

“They fall…motorcycle accidents…Also, lots of intestinal infections, the flu, the children have pneumonia, parasites, women with HIV…

“Many of the Haitians are peaceful people, who come here,” she continued. “Some aren’t. Once, a woman came here with her 5-month old baby. The baby was born with HIV and was already really sick. There was so little we could do. The mom tells us, ‘If my baby dies, I’m going to kill a doctor or a nurse.’ They blame us if something goes wrong, instead of whatever illness they have. Sometimes it’s scary to work here, when you see a large group of Haitians come in, you worry if they might attack you…”

“Yes, there’s a sense of discrimination on their part. They always think we’re discriminating against them, but we don’t. We don’t care about your religion, your skin color, where you’re from – we’re here to treat everyone with the same level of care.”

Jhefri and I walk outside. “Wow,” he says. “I’m learning a lot about my own country.”

“Interesting to hear two sides. The Haitian mother who says she feels treated like a dog, and the Dominican nurse who says they do the best they can with what little they have for everyone.” You ask yourself how honest you can expect people to be when you talk to them about such a delicate subject. Would I have expected the nurse to not say that they treat everyone the same? And when I speak with a group of Haitians, are they not always going to tell me the worst, as they now have a young white American before them and therefore a chance to receive some money? There are ethnographic studies[1] that have described a “victim mentality” among the populations that aid organizations seek to help, going so far as to say that the mentality is both perpetuated by aid policies, and that the aid brokers themselves derive their own power from that mentality. And then, from own point-of-view, I have to keep myself in check. I want to make sure I report all sides to this. It’s natural to have your own set of preconceptions before going into this kind of project.

The relationship between the Haitians and the Dominicans is not so easy to unravel. Before I came here, I read a bit of the history between the two countries, that the Dominican Republic had at one time been invaded by Haiti; that the Dominican sugar industry depends on migrant Haitian labor; that Trujillo, the Dominican Republic’s nefarious dictator, had ordered a systematic campaign to murder thousands of migrant Haitians along the border in 1937; that a structural system of anti-haitianismo, or blatant anti-Haitian racism, has inoculated a sense of racial superiority and ensured that migrants occupy the lower rungs of social and economic existence, as that’s how the system best profits.

But there’s a remarkably inverse flip-side to this. Haitians and Dominicans inter-marry. The majority of Dominicans have some mixed ancestry, overwhelmingly including African blood. Go to the university, and you’ll see Haitian students hanging out with Dominicans. Haitians and Dominicans live side-by-side with one another. Walk into the communities where we’re surveying, and you’ll see Haitians and Dominicans sitting on a patio together. On my first day in the country, taking the bus from Santo Domingo to San Francisco de Macoris, I met a young Dominican student who, upon hearing that I was going to study the health of migrant Haitians, eagerly started practicing the Kreyol lessons that his Haitian roommate had been teaching him at school.

Jean-Peter, one of the research assistants, himself Haitian, came here when he was fourteen years old. He worked in rice fields until he met a Dominican man who took him in as his own son, and helped pay for his schooling. He attends the university, studying civil engineering. “The Dominican Republic is like the mother of Haiti,” he said the day that I met him. The man works his ass off, walking all day under the sun, going house-to-house with me to talk to people. Then he’ll come back from that and listen to recorded interviews I’ve had with Haitians here and painstakingly write word-for-word what is said in the interview. His French isn’t perfect, but between Spanish, French, and Kreyol, we work things out. “Je ferai tous les moyens que possible pour que ton travail va bien,” he always says – “I’ll do whatever is necessary to make sure your work goes well.” And he does. I teased him the other day though. While we were out doing a census, he started flirting with a young woman whom he knew. “I don’t know how much work you’ll get done talking to girls all day,” I said.

The next day, the first thing he said when he saw me was, “Hunter, yesterday you said something that I take seriously. You think I talk to girls the whole day? No. No, no,” shaking his head. “When I work, I work. I talk to the girls later.”

There would be time for that later anyway. He and I had worked every day for two weeks. We finally finished a census in a dusty, hot little village outside San Francisco, so it was time to drink cold beer and dance. The music was so loud I could barely hear myself think.

“Can you dance?” the girl asked me.

“Better than I can speak Spanish!” – that’s how bad my Spanish is.

An old Dominican man in El Ranchito shook my hand vigorously, “Americano!” – he said with a grin, “Around here, we don’t care where you’re from, oíte?

Back at the hospital, Jhefri and I go eat lunch together, Jhefri getting a more Americanized dish of fried chicken and French fries, and me getting rice, plaintains, and chicken cooked in a Dominican sauce. “Haha,” Jhefri laughs, “You eat my food and I eat your food.”

V

But now we’re on the way to the Haitian communities, so we have to take a gua-gua, or unmarked converted Toyota van that is the cheaper end of public transportation. Thanks to having a local research assistant who knows his way around, you go to this little park nearby and walk up to someone and ask, “Where’s the gua-gua that goes to Las Gauaranas?”, Las Guaranas being one of the communities we need to visit to do a census, noting how many Haitian households there are, and approximately how many people live there. The number of houses will be the most reliable piece of data we can hope to get, as it’s unlikely the people we’ll be talking with won’t always be so forthcoming in divulging how many Haitians live with them, and that’s understandable.

You get crammed into a van with more people. You sit with your hips jammed in next to someone else, both of you sitting there sweating, and even after you think nobody else could possibly be fit in next to you, the gua-gua stops mid-route through the journey, along the side of the road, for a woman who’s standing there hailing us down, and someone inside yells, “Lleva la!” “Pick her up!”, and then the guy next to you yells up,”Chofer!” – “Driver!” – “Business sure is good today, eh?” and everyone laughs. The inside of the gua-gua can be the center of great discussion and debate too. Unlike back home, where people rarely acknowledge the strangers they find themselves standing next to in an elevator or sitting next to on a bus, people here get involved with one another, talk, laugh, debate, argue, even if it’s only for the 15-minute ride outside town. And while maybe a bit uncomfortable, you’re happy because you only had to pay 50 Dominican pesos for this ride, much cheaper than a taxi, and it’ll take you outside the city, out towards the rice plantations, where you hope to do the census.

That’s what’s so remarkable about the lay-out of this place – you leave somewhere that can feel packed and loud and crazy, and then you get out of an old Toyota van and find yourself in the middle of the campo, on a dirt road with kids riding bicycles staring at you and a tractor that rumbles past you.

VI

What’s a Haitian community, anyway? From what I’ve seen thus far, Haitians in this area do not live in segregated communities like the batayes in the south, where they live in barracks on the sugar estates. Here, they live in poor little communities alongside Dominicans. They can be found in more urban neighborhoods and out in the countryside. For the purposes of this project, we’ve selected five communities outside of town where Haitians tend to live in clustered little communities mixed with Dominicans. These communities were selected because of their proximity to the urban core of San Francisco (and therefore their purported use of its healthcare facilities), and through discussions with our Dominican partners who have had an interest in learning more about these specific communities. While we may be sampling from communities in which many work in the nearby rice fields, I’ve also encountered Haitians who describe themselves as “electricians” and “mechanics” and “metal workers” within the same community, hinting at more variability than thought.

The challenge to sampling within these communities is being sure to randomly sample only Haitian households, and do it in a way that’s representative of the Haitian community. When the spatial configuration is such that one or two Haitian households may be followed by three or four Dominican houses, and vice versa, it becomes difficult to assume that you can interview “every nth house.” There’s ways of getting around this, and I can attest that I was left scratching my head at considering the options. One of the most thorough ways, and one that will be really valuable in later studies, is an actual census of Haitian households – literally walking the community street by street, noting where Haitians live, drawing a map, and then numbering those houses. From there, you can pick which houses to sample from.

So that’s what Jean-Peter and I have been doing this last week – riding out to these communities in gua-guas and pick-up trucks and introducing ourselves as part of a research project from America that wants to understand the health problems in the Haitian community. Would you mind if we came back later to ask more questions? We can’t pay you to participate, but your answers will help us understand the problems here. You can choose not to participate too. This is, after all, your community, and we are guests…

And this has its challenges. For one, it isn’t always easy to find a Haitian house among Dominican houses. There are houses with decent roofs and nice, cleanly swept cement floors and even chairs with cushions on them – those houses do tend to be Dominican. However, the houses that tend to exemplify the standard of living most Haitians seem to have – where the roofs are fashioned from whatever scrap metal they find, the floors are dirt, the walls are built from sticks and more sheet metal and, among the poorer families, from woven sacks – these houses can just as likely be inhabited by poor Dominicans. It’s just that every time we stumble upon a house that seems very nice, it’s unlikely a Haitian family lives there. At times, I would see a house that looked “poor enough to be Haitian,” but Jean-Peter would correct me with the reminder that “Haitians don’t have furniture” – and sure enough, by peering through the front door from the street, there was a table with wooden chairs.

If nobody is home at a house that you suspect deserves to be counted, sometimes it’s easy enough just to ask a neighbor. Maybe there’s an older Dominican woman hanging clothes out to dry on a line. “Excuse me ma’am, we’re doing a research project about problems in the community, and would like to know if Haitians live in that house. If so, could you tell us about how many?” People are more than willing to help I’ve found.

VII

Now we’ve found a house with a Haitian family. A young man is holding a little baby girl in his lap, and a woman is washing clothes in a plastic tub, who gives us a wary look. He’s sitting on a concrete block and there’s a little charcoal fire nestled between rocks. We introduce ourselves, thoroughly explain that we’re not working for lapolis or migrasyon – police or migration officials – and that we’re here to talk about health problems in the Haitian communities. Would he be able to tell us how many people live here in his house? And how many different families among them?

Because what we’ve found here, further complicating the sampling strategy, is that one house does not necessarily mean one unique, nuclear family. One physical house may accommodate, say, 12 people, belonging to two or three different families. I’ve seen a house of two rooms with fifteen people living in it. And how about a house that accommodates a group of friends? Or cousins? Who is the “head-of-household” then? Jenny had an interesting point:  some sampling strategies attempt to simplify this predicament with the definition of a “household” as “those who eat together.” Overall, I’ve found that the number of houses in a community doesn’t really tell you anything about the size of the population there.

Now, a survey seeks to collect information in a neat and systematic way in order to be analyzed later. There’s open-ended questions, like, “Why did you leave Haiti?” and the participant can respond however they so choose. Or there’s close-ended questions, such as “Did you leave Haiti because of the earthquake?” to which they’d reply with either “yes” or “no.”  I have five surveys, for which I hope to recruit 100 people sampled systematically across these communities so that each community is appropriately represented.

Each of these surveys seeks to acquire different information. The first is a migration history and perceptions of illness screener. There are basic questions in it:  “where are you from in Haiti?”; “Did you know anyone in the Dominican Republic before you came?”; “Have you always lived in this community, or elsewhere?” There are questions about their own livelihood and security, such as, “In the last year, for how many months did you not have enough money to feed yourself or your family?” and “Have you or someone you know ever been robbed or attacked?” or “Have you or someone you know ever been questioned by the police or migration authorities, or deported from the Dominican Republic?” ….more on those questions later….

By “perceptions of illness,” we ask each participant to cite the most common illnesses they had in the last year, followed by men, women, and children. For each illness cited, we ask them to name it in Spanish, if they can, and where they go first to seek care. This information will be especially useful for our Dominican friends, because it will help us understand where Haitians prefer to go for care and for what illnesses they consider most important. It may also lead to a mini-Kreyol-Spanish dictionary.

There are three screeners specifically designed to assess mental illness. Along with two for depression and anxiety, another is an “idioms of distress” screener. Idioms of distress are unique, culturally meaningful ways that people from other cultures use to describe some sense of suffering. Last summer in Haiti, we identified certain idioms that pertain, to some degree, to expressions of mental illness. An example is tet pati, which literally means a “head that has left,” and can be used to express a range of experiences, from forgetfulness to an inability to concentrate. The survey has a list of these idioms, and asks the participant to describe how often they’ve experienced them.

Finally, we have a functional impairment screener. In order to assess how severe a mental illness may impact someone’s life, we need to see if, to any degree, they are unable to complete those tasks deemed most relevant to their lives. But how do you go about determining those tasks that are most relevant? What may be important to us in Atlanta may be entirely different in a migrant Haitian community in the Dominican Republic.

You ask men and women separately, what are the things you have to do to take care of yourself, your family, and your community? You list each item as they begin reciting them, noting what they say first, then second, and so on. This indirectly tells you the importance of items, since it’s assumed that the first item they list is the most important. You can then compile a tally of certain items, and get an idea for what is most important for taking care of one’s self, one’s family, and one’s community for both men and women.

And the items we’ve come away with are absolutely fascinating. For both sexes, “work” and “eating food” or “giving my family food” are frequently listed items. People have said, “Go to the hospital,” yet interestingly, in different categories – either for one’s self, or for one’s family. “Go to the hospital” was the most commonly cited item for women to take care of themselves – whereas more men cited “Work” first to take care of themselves, then followed by “Go to the hospital.” Also interestingly, more women cited “Work” as the most important thing to do to take care of their families, followed by “Send them to the hospital,” and “give them food.” For men, to take care of their families, they cited “Send the kids to school” – an item that was absent for women in that category. It would appear that men may place higher priority on sending the kids to school than women. For community items, men and women cited tet ansanm – that same social system of organizing to accomplish tasks that we saw in rural Haiti! It will be very interesting to see how they use tet ansanm in this context. Men and women also said that it’s important to “Go to meetings,” “Wash my hands,” “Clean the street so cars can pass” – cars they’ll never drive – and “Drink clean water.”  Overall, it would seem that women prefer to go to the hospital and work in order to take care of themselves; work, give advice, and give food to take care of their families; and do tet ansanm and go to meetings to take care of their  communities. Men work, go to the hospital, and eat to take care of themselves; work and send the kids to school to take care of their families; and do tet ansanm to take care of their communities. While all these items appear to be the same for both sexes, you can see where subtle differences in priority lie.

One last item that was absolutely eye-opening to me was a consistent mentioning of “Live in peace;” “Have good behavior;” or “Respect the opinion of others.” Both men and women cited items under this theme of “living peacefully” as ways to take care of themselves, their families and their communities. I’m suspecting that all of this means that they seek to avoid trouble with the Dominican authorities and population around them, as this item never occurred to a high enough degree when we asked people the same questions in rural Haiti.

Taking all of this together enables us to piece together a rudimentary “functional assessment,” in which we ask men and women separately how hard it is for them to do those tasks that they consider most important. Paired with a screener for depression and anxiety, it may point us in a direction that indicates mental illness that may cause impairment in daily functioning.

Of course, what is important for us to tease apart in all this is to distinguish the reasons people cite for causes of their difficulties. First, people are asked to describe their level of difficulty using a pre-formulated scale, ranging from “No difficulty,” to “A little difficulty” and finally, “Often I can’t do it at all.” To help people conceptualize this scale, we have an image of five pictures of a man carrying a load of rocks, with each picture depicting the man carrying a heavier load, to the point that he is on all fours, the load too large for him to carry. Each picture represents how much difficulty the participant has in completing an important task, and we ask the participant to point to the image that best corresponds to their level of difficulty.

I’ve found that it is extremely difficult to do this at times. It seems hard for Haitians to assign the difficulty they experience in doing certain things to a confined category. “Do you have no difficulty, a little difficulty, a moderate amount of difficulty, a lot of difficulty, or sometimes you can’t do it at all?”

Some don’t understand that we need them to pick one of these choices. I remember one older Haitian man, sitting bare-chested in a chair in front of his house while maybe a granddaughter was shucking peas, get up when he saw us coming, entered his house, and came back outside with a little New Testament in his hand. Like nearly every Haitian household we visit, people got up to offer us their chairs. He came back out, and Willy, the other Haitian research assistant I hired, proceeded to ask him the difficulty he had in doing certain things in life, like working, or feeding his family.

“Listen close papi,” said Willy, “Work:  do you have no difficulty, a little difficulty, a moderate amount of difficulty, a lot of difficulty, or sometimes you can’t do it at all?”

The old man shifted a bit in his chair as his granddaughter kept shucking peas. His wife was braiding another young woman’s hair and stared at us. “Bon,” he started, looking off into the distance. “Well, you know how it is. You have papers, or you don’t. I’ve lived here for sixteen years, thanks to God. We have many difficulties here….”

Willy held up his hand. “No papi, listen to me. You must choose.  Work:  do you have no difficulty, a little difficulty, a moderate amount of difficulty, a lot of difficulty, or sometimes you can’t do it at all?”

Bon…” It’s hard not to give people the time they’d need to share their stories, to allow them the time to explain themselves, and ask them instead to describe how hard it can be by choosing a description of their difficulty on a scale. But for the purposes of this project, we have to do it that way.

VIII

But then you got to figure out why it’s difficult. Migrant Haitians, when asked why it’s hard for them to work, will not say, “Because I’m depressed.” More than likely, they will say, “Because there are no jobs here.” Why is it hard to provide food for your family? “Because I have no money.”

You begin to see how simple a problem may appear:  with no job, you make no money, and without money, you cannot feed yourself or your family, send your kids to school, or go to the hospital. Your existence boils down to this formulaic model.

It’s simple but it isn’t. Haiti was the first independent, free, black republic in the New World. Before Haiti won its independence, it was a slave colony of the French, and not just any of its colonies; it was its richest, exporting the majority of the raw materials that contributed to the wealth of monarchic France before their own revolution in 1789. The slaves in Haiti, a colony then called “Saint-Domingue,” in turn revolted, only a bit later, against a France that was ruled by one of the greatest European military strategists in history, Napoleon. These were slaves, remember, that fought against, and eventually won, their independence from the most powerful dictator of the time, in 1804. The other slave-holding powers of the era, including the United States, did not recognize Haiti’s independence until later. France made Haiti pay “reparations” for the lost wealth that ensued in order for it to be recognized as a free nation. I do not personally think that it’s by coincidence that the first free black republic in the New World has also become that hemisphere’s poorest.

When people cite a lack of work or money for reasons why accomplishing the most basic of tasks are difficult, their responses are similar to those we saw in Haiti. Yet here, a whole new set of explanations were also offered: “Because the Dominicans do not want us in their country;” “I do not have [immigration] papers;” “I am not in my country;” “The president does not care about us.” And, even more startlingly: “We want to do a tet ansanm with the Dominicans, but they do not want to.”

This is tough to hear. I come home at the end of the day with a handful of screeners that we piloted earlier that day, and I try to sort the responses into an Excel spreadsheet. I go through each screener, where Jean-Peter or Willy painstakingly wrote each participant’s word-for-word reason why it was hard for them to do what is necessary to take care of themselves, their families, and their community. Each little note is one person’s way of explaining the mess they and their families find themselves in. “I have no money;” “The Dominicans do not want us here;” and as you go through the screeners, it starts to repeat itself over, and over, and over again. A twenty-nine year old female market vendor in Las Guaranas; a forty-two year old man in El Ranchito; a thirty-three year old unemployed man in Caimito. Mwen se yon malere mwen ye – Me, I’m just a miserable one – or, pwoblem diskriminasyon – and then I come across this: “Because Haiti is a country of misery, and here it’s still misery.” And here I am trying to take it and put it into a neat, Excel spreadsheet to tally. At times, beer has become my comfort mechanism.

I tried interviewing this young man in Caimito about the problems he’s encountered living in the Dominican Republic. He was cleaning his little motorcycle next to his shack, as that’s all it was anyway. Se vende – For sale – was spray-painted across his front door. I picked him out because as I passed by him, he briefly spoke to Willy, and afterwards Willy said, “He wants to go back to Haiti because he doesn’t like it here.” I instantly wanted to talk to him. He was, at first, very warm and receptive. I tried to explain that I was from a university in America (Jean-Peter, for convenience’s sake, often tells people that I come from “the university in New York”). I wanted to record our conversation, if he didn’t mind, and again reassured him that I wasn’t part of the migration authority, and could he please describe how he crossed the border, what kind of work he’s done, what the relationship is like between the Haitians and Dominicans…and his answers were always short. I kept trying to get him to open up more, and his smile faded, his eyes became hard, and he asked me, point-blank, what exactly I was going to do to help solve these problems he was describing for me. “Aren’t you a little late anyway?” he said.

So that can be tough. And then sitting with a group of men, all rice farmers, who work six out of seven days of the week, all day in a rice field. They recounted to me stories of unprosecuted murder. Murder over a lost cow, for example. I could barely hold my head up when I heard that story. I looked up at Willy, who said to me in French, “This is a crime.” It’s more than that.

Or stories of Haitian women who go to a clinic, and when the provider assumes she doesn’t understand enough Spanish to defend herself anyway, proceeds to sexually assault her. Like many other places in the world, there are horrible things that go on down here.

It’s hard. I’ll knock myself from time-to-time. I wonder who the hell I thought I was coming to a place where I can barely navigate the native language, and attempt to understand the mental health of a people who are the absolute underdogs in a country that has its fare share of poor and is direly short on resources in its own right. But I was reminded by a friend that no matter what results from this project, and even if (more than likely) I just knick the surface of these problems that are systemic and across-the-board, it’ll be useful information, and may help us better understand a population that has been neglected for far too long.

 

 

 

Oken peyi pa fasil pou nou – No country is easy for us

 

Sylvie* left Port-au-Prince when she was pregnant with her first child, at age 18, because her boyfriend was beating up on her, and her mom decided that the best thing for her to do was to move to the Dominican Republic. At least over there there’s sekirite – security – and more job prospects. Sylvie didn’t know a soul here, when she arrived in San Francisco de Macoris nine years ago. But she figured out how to make a life for herself, amidst all the pain and struggling and seemingly endless little battles migrants must take on, day in and day out.

When I first met Michele*, I could tell she was sizing me up, as if to say, “What are you all about?” She spoke Kreyol too fast for me, but I understood when she invited me back to her little shop where she sells clothes, in San Francisco’s permanent market area on the other side of Avenida de Libertad, so we could talk. In retrospect, I think all that I managed to say in intelligible Kreyol was, “I’m here to do a project about problems, the problems the Haitians have, health problems, and I’d like to hear your story.”

Michele, like Sylvie, also dropped out of school in order to come here. She was 7 years old when she left Jacmel, on Haiti’s southern coast. Her mother had already emigrated and started a rather decent business selling wholesale clothes, and so she followed after her. Ever since, she goes back and forth between the two countries. She lives with her little brother, her mom, and a group of other Haitians who all left together in the same car to come here.

I met both of these women while walking around looking for Haitians to talk to. Here in the Dominican Republic, Haitians can usually be pretty easily spotted – they look more African than their Dominican neighbors, and they also occupy rungs towards the very bottom of the economic ladder. This means pretty menial lines of work – carrying handfuls of pirated CDs in your hands that you’re trying to sell to passers-by; standing at an intersection trying to cell phone cards to drivers parked at red lights; mixing and pouring cement at a construction site; bent over in a rice field under the sun; or wearing a ridiculous neon-colored uniform that advertises the brand of pop-sickles you’re toting around on a little cart beside you. Haitian women tend to be found in markets, often sitting on plastic buckets or milk crates, next to a table with little bars of soap and knock-off brand sandals and clothes.

Traditionally, migrant Haitians have worked most predominantly in the Dominican sugar industry, namely, cutting sugar cane during the zafra, or harvest. The industry grew exponentially, thanks in no small part to the cheap labor that the Haitians provided. There are accounts of the Dominican authorities turning a blind eye to the illegal status of many of the laborers; of corrupt passeurs – intermediaries – misleading Haitians into contracts that bound them to work. There are accounts of second and third generation Haitians, born on Dominican soil, who still have no documentation of their birth, which would entitle them to automatic Dominican citizenship. And the poor quality of life on these sugar estates has been well publicized.

I write this only to gain some perspective. Haitians have been migrating to the Dominican Republic for decades now, and each country has contributed to the history and culture of the other. Everyone knows that Haiti is a poor country, and the Dominican Republic, in some ways, is decades ahead of it. It comes as no surprise that people would look for work here. The labor sectors that employ Haitians have expanded beyond the bateyes, or Haitian communities on the sugar estates. Now, rice, coffee, and cacao farms employ Haitians; construction sites in bustling cities depend on Haitians; and while they typically work in low-paying jobs, they have also moved up the economic ladder, steadily improving their lot in successive generations.

The tension, however, between the two countries can be palpable at times. While most Dominicans share some degree of African descent, and while I would argue that most Dominicans are not racist, there is a dark history of anti-haitianismo, or anti-Haitianism, that some would argue still contributes to a structural system that keeps Haitians down, that always highlights the differences between the two (and casts the Dominicans in a superior light). “They’ll treat a Haitian like a little toy,” said Sylvie, in describing interactions with migration officials. In order to obtain a cedula, or work permit – a permit that would enable its bearer to apply for more respectable jobs than selling bars of soap in a dirty street market or bent over in a rice field – the applicant must pay $225 – American dollars – a sum that is beyond the means of anyone who comes from a country where more than half the population lives on less than $2 per day. “I’m not trying to go to Miami, I’m not trying to go to New York, I’m just coming here to the Dominican Republic, and they want me to pay $225?” asked Michele. And without the cedula, they do what they can.

I’m here for six weeks to learn about the migrant Haitian communities in and around San Francisco de Macoris, the city where colleagues at the School of Nursing have long collaborated with their Dominican friends at the local university here, where they have worked together on community-based projects and conducted an annual Alternative Spring Break trip with Emory nursing students.

More formally, this project sprung from another that I was involved with last summer, in Haiti. There, I helped gather information about the perceptions of mental illness held by rural Haitians – what mental illness meant to them, how they explained the causes of mental illness, and where they went for care. Part of our project was to create screening instruments that lay community health workers could use in their own daily activities, so that they can identify persons with mental illness, and refer them to existing sources of care.

Here in the Dominican Republic, I hope to use those same screening instruments in the migrant communities to get a sense of their mental health burden. More broadly, I hope the information I gather from these screening instruments will be part of a larger picture of this community, one that includes not only mental health, but individual stories of migration, of working and living here, and where the biggest gaps are.

And yet focusing solely within the Haitian communities themselves would only give us half the story. To better understand what is happening here, we must talk to the Dominicans who employ Haitians, to the Dominicans who provide healthcare and other services to them, and to those who help create the policies and set the political tone for them.

There’s no way in the world I could do any of this alone. I’ve already been enormously assisted by my Emory faculty mentors, namely, Dr Jenny Foster and Dr Brandon Kohrt. Before departure, Yvonne Hewitt, Martir Herrera and McLain Mallory helped me with translation work, and Sarah Gossett helped me obtain letters of support from in-country partners at the public hospital.

Since I’ve been here, my “host mom” Rosa Burgos, a nursing school professor here and one of Jenny’s closest friends and collaborating partners, has literally taken me by the hand and helped me get to where I need to go. And just today, Dir. Rafael Alvarez, director of the local university, personally took me on a drive into two migrant Haitian communities, discussing what could be done. Finally, I’m working closely with a hired research assistant, Jean-Peter, himself Haitian, who studies civil engineering at the university and, thanks to him tolerating my capacity to mix three languages in the same sentence (Spanish, French, and Haitian Kreyol), manages to get the job done.

In the spirit of an on-going collaboration with our Dominican partners, this is really a project whose aim is to lay a foundation for more work, for increased attention on the needs of  a population that is nearly invisible. What we learn from the next six weeks is to be shared and made available to all interested, and to all who could benefit from it – including ourselves as nursing researchers, our Dominican partners, and of course, members of the Haitian communities themselves.

 

*I’ve changed the subjects’ names to protect their identity.

 

Holy cacao!

Today was our final day of home visits, and we more or less had our routine down by now. We dropped off Kathleen, Sara and Hunter (who joined us for the first time today and will be here for a few more weeks completing his community health rotation) in the first community along with a couple of Dominican coworkers, and they completed 2 home visits/community surveys. Since they were dropped off first and the rest of us traveled so much farther, they also had extra time to get to know the local roadside cantina. Translation: they patiently waited for our bus to return for 2 hours after they finished their work.  Every day is a lesson in flexibility!

The rest of the group developed a system in which half of us would complete the home visit while the other half performed community surveys. This way, everyone had the chance to visit 1-2 families and to see different communities. We sat in rocking chairs under trees and spoke to community founders, we surveyed the local parks and we chatted with anyone and everyone we could find about resources, problems and benefits in their communities. The nurse in charge of all childhood vaccines for the municipality also joined us, and with her help we had a much easier time tracking down families.

Since we did have more down time today on the bus, we were able to begin analyzing our data for our presentation tomorrow. We also conducted and recorded interviews with local nurses, community leaders and students. We hope to use these interviews in multiple future presentations. Each interviewee brought a different perspective to the project and, as always, it was very inspiring to hear the empowerment and excitement in their voices.

After lunch and a brief meeting at the hospital we spent the rest of the afternoon at the cacao farm owned by Catharine, Darya and Rachel’s host family. Manuel (our host father) proudly showed us how cacao grows and how it is dried. We also tasted dried and fresh cacao. Most of us prefer chocolate in its processed form, but it was an experience! The farm was beautiful and more than one of us wanted to stay longer. After sharing snacks in the shade at the farm we headed home to San Francisco de Macoris. This afternoon was only a sliver of the generosity and welcome we have received here. We cannot believe the week is ending so quickly, but hopefully we will make the most of our final day here!

Gracias, Catharine, Kathleen and the DR team

Dia del campo

Today, we went out in to the “campo” or countryside surrounding San Francisco de Macoris to search for mothers involved in the Kangaroo program. Our first stop was a small village called Las Matas de Cotui. The mother had triplets who were 9 weeks old. She would “kangaroo” 2 of them at a time. Although they were relatively healthy, each child had some kind of medical problem. One had thrush, another had club feet, and another had a functional heart murmur. But it appeared that they were all gaining adequate weight and improving. Only a few went in to the house, and the rest of us went to survey the surrounding community to get a better feel for where the children will be raised and what their environment will be like. There are photos below of the triplets and the community. We proceeded to drive through the countryside. We stopped at the other hospital, and we got to compare Then we went to another village called Las Guaranas. This area was a little more developed. Here, we saw another set of triplets; however one of the triplets had died shortly after birth. The two surviving children were around 18 months and were doing quite well.

To continue our animal/breastmilk saga, Sara H. found the kitten of the house cat “Pooka” this evening.  We named her Kanga- for Kangaroo. She looks to be about 5 or 6 weeks old as well, and she thoroughly enjoyed Stephanie’s breastmilk as well! Sarah G, Sara H., and Kathleen have had so much fun playing with all their baby animals! Jenny says this is the year of the animals; but we say it is the year of the babies! Kittens, puppies and babies, oh my! The puppies are doing great and are growing so fast. We know they will probably be the saddest to see us leave!

Tomorrow, we will go visit more mothers and babies in the morning, and in the afternoon we will go through our data and begin our presentation for the hospital on Thursday afternoon! We are also hoping to get to visit the “coco” farm of one of our Dominican friends. One of the most important parts of our work here is continuing to build a relationship with the local hospital, and not just “impart knowledge” on the people here, but help them figure out what works best in their individual situation. By forming a relationship with and empowering the health care staff and community leaders, we hope to provide a sustainable way for them improve the quality of care for the people of San Francisco de Macoris, the Dominican Republic, and the rest of the Caribbean.

Gracias,

Kathleen, Catharine, and the DR Team

Here are some pictures from our trip so far! (Today was the first day we could upload some of them)

Welcome!
Our welcoming committee at the airport!

Our first day, just after orientation


Yes, the beach really was this beautiful

These were two of the triplets- the mother would “kangaroo” two of them at a time

This was in the village where the triplets live.

The newest member of our household! Kanga!

Dia de trabajo

Today was our first day of work, and it was both exhausting and exhilarating.

We began our day meeting with the Dominican students and nurses to organize teams and supplies. We received a very warm welcome from hospital administrators, the hospital director and a senator. The hospital director and senator both emphasized that they believe project such as this are what will improve the health of the community and, consequently, of the country. The hospital director also shared his hope with us that Hospital San Vicente will one day be internationally recognized as a research institution. It is truly inspiring to see the passion our hosts have for their community and country, and truly humbling to realize we are collaborating with them on such a significant project.

We divided into teams of 2-3 Dominican students, a Dominican nurse or medical resident, and 1-2 Emory students and spent the rest of the morning and afternoon in the surrounding neighborhoods visiting Kangaroo families. Some groups were more successful than others in tracking down families, but in total we managed to evaluate 30 Kangaroo babies today. The parents were extremely proud to show us their children, and understandably so—these babies, who participate in the program because they were born prematurely or with low birth weight, were almost all thriving and healthy!

Unfortunately, not all stories are complete successes. One group evaluated a baby who had had multiple complications, including hydrocephalus. Another group went to a house only to find that the baby had passed away at 2 months of age. These stories, along with the many positive outcomes, are what give the program both hope of success and reason to continue.

A few of our group also had the chance to tour the hospital this afternoon. Perhaps the most significant difference they noted between our hospitals at home and the hospital here was the lack of resources, particularly in the ICU. We take monitors and machines for granted, here they are a rarity. It’s interesting to remember that intensive care does not only mean intensive technology, but also (and importantly) intensive nursing attention.

Tomorrow is another busy work day in communities farther from the hospital. We can’t wait to see what it will bring.

Gracias, Catharine, Kathleen and the DR team

Vamos a la Playa

Today was our day to go to the beach! It would have been wrong to spend so much time in this beautiful country and not experience the beaches. We took a ~2 hour bus ride to Playa Grande, and we had a great day relaxing, getting to know each other, and seeing why the tourist industry thrives in the DR. We had local food on the beach- most of us had local fish, rice, and fried plantains. It was delicious. Then we also had “pina coladas”, which were actually entire pineapples scooped out and crushed up with ice and some coconut. They were quite a treat as well! It truly was a perfect beach and a perfect day.

Tomorrow, we begin our real work with the local nursing students visiting the homes of the mothers involved in kangaroo care. We will ask each mother some questions about their child’s development, as well as take measurements of the children to further assess their growth. We are all excited to begin our work and look forward to keeping you up to date on our progress!

Adios,

Kathleen and Catharine and the tanned (and slightly sunburned) Emory DR team